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Background

Background

Introduction

When Alexander Fleming first discovered penicillin over 70 years ago, he predicted that microbes’ Darwinian ability to evolve and survive would result in the development of antibiotic resistance, said Chair Prof. Oxford in his opening address.

That prediction has come true, with resistance becoming a global concern. The challenge this poses for the future has been starkly outlined by the World Health Organization (WHO), which warns that antibiotic resistance may increase the cost of healthcare and jeopardise the healthcare gains made in the last 100 years by threatening a return to the pre-antibiotic era1.

While the rates of antibiotic resistance vary across the globe, there is a direct relation between the use of antibiotics and the emergence of resistance at both the individual and population levels2. A recent WHO report called for the rational use of antibiotics in humans and animals, and improved infection prevention and control to help combat antibiotic resistance2.

In support of the WHO initiative, the inaugural meeting of the Global Respiratory Infection Partnership was held at the Royal College of Physicians, London, to discuss experiential learning from around the globe and strategies to drive the rational use of antibiotics among patients and healthcare professionals. Comprising a multidisciplinary, international group of general practitioners, microbiologists, researchers and pharmacists, spanning primary and secondary care, the Global Respiratory Infection Partnership focused on how the management of sore throat could be utilised as a marker for rational antibiotic treatment.

A clear call to action was summarised by Prof. Essack: “We need a multiple-pronged, multi-country, multiple-stakeholder co-ordinated approach to antibiotic resistance that is linked to a concrete intervention, not just a leaflet or a poster.”

The Global Picture

The meeting began with an overview of antibiotic prescribing, resistance rates and awareness campaigns from around the globe. Some consistent issues emerged:

general practitioners in primary care are the primary healthcare professionals for rational antibiotic prescribing

there are few new antibiotics in development and those that are currently available should be used sparingly

even in countries where antibiotic use is low, rational prescribing can still be improved

although guidelines exist in many countries, uptake and implementation is often poor

in many countries, antibiotics for upper respiratory infections are available for sale through pharmacies, despite their prescription-only status

healthcare professionals believe patients/parents presenting for consultation of respiratory tract infections wanting an antibiotic may be seeking simple reassurance, complaint prognosis, symptomatic relief and/or a ‘sick note’ to justify time absent from work

healthcare professionals’ communication skills can be enhanced to effectively deliver the ‘antibiotic is not required’ message to patients

patients believe that antibiotics are an effective treatment for common respiratory tract infections, even those of a viral nature.

Perceptions & Misperceptions

In many countries there appears to be a disconnect between what healthcare professionals perceive patients want from a consultation and what patients actually want.

“My theory is that GPs feel under pressure to prescribe; that patients urge them to prescribe or they will either come back or go to another doctor”

said Prof. Altiner. Yet, he cited data that show only a small number of patients expect a prescription3. Patients are more concerned about prognosis and symptomatic pain4, 5, he added.

Prof. van der Velden added that the reasons for consulting a physician can be cultural. In France, 50% of patients with common cold present for a consultation, whereas in the Netherlands 1.2% consult their physician. Obtaining a sick note to legitimise being off work is one of the reasons explaining this difference.

Socioeconomics also plays a role. In Italy, antibiotic use is higher in the poorer Southern regions than in the North; an observation also seen in Brazil and the UK. Dr Duerden commented: “Deprivation is a strong driver for antibiotic use and we don’t know why”. Prof. Pignatari suggested that doctors perhaps spend more time with richer patients, affording greater opportunity for discussion and explanation on rational antibiotic use, while poorer people get more antibiotics.

Whatever the drivers, providing a prescription creates a message to the patient that antibiotics are the right treatment. Research in sore throat has shown that when doctors don’t prescribe an antibiotic, patients are less likely to return for treatment in the future6, said Dr Duerden. “But, in the UK, patients who see the doctor for selflimiting infections tend to get an antibiotic prescription”.